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A Look at The Joint Commission

Joint Commission, NQF Announce Recipients of 2021 Eisenberg Awards

Lenworth M. Jacobs Jr., MD, MPH, FACS

June 1, 2022

The Joint Commission and the National Quality Forum (NQF) announced the recipients of the 2021 John M. Eisenberg Patient Safety & Quality Awards in April. They were:
  • National Level Innovation in Patient Safety and Quality: Prime Healthcare Services
  • Local Level Innovation in Patient Safety and Quality: Kaiser Permanente Northern California
  • Individual Achievement: Hardeep Singh, MD, MPH
  • Lifetime Achievement: Mark R. Chassin, MD, FACP, MPP, MPH

The Eisenberg awards were established in 2002 as a tribute to former Agency for Healthcare Research and Quality (AHRQ) Administrator John M. Eisenberg, MD, MBA—an impassioned advocate for healthcare quality improvement and a founding member of NQF’s board of directors. The awards recognize individuals, organizations, hospitals, and healthcare systems that have made significant and long-lasting contributions to improving patient safety and healthcare quality.

“The John M. Eisenberg awards were created to honor the enduring legacy of Dr. Eisenberg,” said David W. Baker, MD, MPH, FACP, executive vice-president, division of healthcare quality evaluation, The Joint Commission. “Twenty years later, they continue to showcase how innovation and dedication to process improvement can lead to sustainable solutions to some of healthcare’s greatest challenges. The recipients of this year’s Eisenberg awards uphold Dr. Eisenberg’s life’s work and those who have come before them in furthering the mission of improving patient safety and quality of care.”

Kaiser Permanente Northern California

Kaiser Permanente Northern California was selected for its initiative that developed a predictive analytic scoring system called Advance Alert Monitor (AAM), which proactively identifies patients with a high risk of mortality or transfer to the intensive care unit (ICU), including integration of life care planning or palliative care. AAM alerts clinicians 12 hours before clinical deterioration, permitting early detection and more nuanced response. AAM analyzes electronic health record (EHR) data for medical and surgical inpatients, and then alerts the virtual quality nurse consultants who connect with rapid response teams at the patient’s bedside to develop a care plan. This system combines predictive analytics and has 99 elements, including laboratory tests, vital signs, neurological status, pulse oximetry, and all outpatient and inpatient diagnoses in the preceding 12 months. The AAM score is generated every hour on medical, surgical, and telemetry adult patients.

The program standardized the workflows for addressing inhospital emergencies and the needs of patients near the end of life. Evaluation of the program showed statistically significant decreases in mortality, with 550–3,020 lives saved over 4 years. Data supplied with the application also indicated:

  • Lower unadjusted incidence of ICU admission
  • Shorter hospital length of stay among survivors
  • Lower inhospital mortality
  • Lower mortality within 30 days after an event reaching the alert threshold

Prime Healthcare Services

Prime Healthcare Services was selected for developing and implementing a cohesive and systemwide approach to addressing social determinants of health (SDOH) that links and addresses SDOH to patient outcomes. By assessing patients’ SDOH needs, Prime Healthcare Services helps providers more effectively deliver patient care and reduce healthcare disparities. Its facilities engage senior leadership, strengthen relationships with community partners, and develop digital workflows that promote real-time patient monitoring and data use. To reduce healthcare disparities, Prime developed a roadmap to:

  • Identify SDOH needs based on an opportunities index
  • Design and implement care interventions
  • Establish bidirectional flow of information

After implementing their new screening tool, community partnerships, and bidirectional communications flow, Prime Healthcare Services observed improvements in all-cause hospital-wide readmission rates.

Dr. Hardeep Singh and Dr. Mark Chassin
Dr. Hardeep Singh and Dr. Mark Chassin

Dr. Hardeep Singh

Dr. Singh, chief, health policy, quality, and informatics program, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and professor, Baylor College of Medicine, Houston, was selected for being a pioneer in diagnostic and health information technology (IT) safety. Some of his significant accomplishments include:

Developing “E-trigger tools,” sophisticated EHR-based algorithms that identify patients with missed opportunities in the diagnostic process

Working with the Agency for Healthcare Research and Quality to develop tools and resources to measure and improve diagnostic safety, including “Diagnostic Safety Measurement for Learning and Improvement: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events” and “Common Formats for Event Reporting–Diagnostic Safety,” a standardized reporting format using common definitions to report diagnostic errors

Codeveloping an eight-dimension sociotechnical model that now is accepted as a paradigm in health IT and patient safety work and the Office of National Coordinator for Health IT (ONC) Safety Assurance Factors for EHR Resilience (SAFER) guides that help hospitals perform a safety assessment of their EHRs to address a range of patient safety issues related to health IT use

Conducting foundational research on defining and measuring diagnostic error, some of which influenced the 2015 National Academies report, Improving Diagnosis in Health Care, which cited 32 papers he authored on diagnostic safety

Dr. Mark Chassin

Dr. Chassin, president emeritus of The Joint Commission, was selected for a lifetime achievement award after leading The Joint Commission for 14 years, during which he made profound changes, such as shifting accreditation away from simply citing deficiencies and toward helping to drive improvement. A key part of his effort was the creation of The Joint Commission Center for Transforming Healthcare to work with the nation’s leading hospitals and health systems to create effective solutions for healthcare’s most critical safety and quality problems, including healthcare-associated infections (HAIs), hand-off communication failures, wrong site surgery, patient falls, and healthcare-associated pressure injuries.

He also ushered in great change to The Joint Commission’s internal improvement culture by introducing Lean, Six Sigma, and change management concepts and tools that were later incorporated into The Joint Commission’s Robust Process Improvement. Moreover, Dr. Chassin was a member of the Institute of Medicine committee that authored To Err Is Human and Crossing the Quality Chasm. He is a recipient of the Founders’ Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability.

Selection Panel

The 2021 Eisenberg Award Panel consisted of:

  • Carolyn M. Clancy, MD, MACP, Department of Veterans Affairs, panel chair
  • Brent C. James, MD, MStat, Clinical Excellence Research Center, Stanford University School of Medicine, CA
  • Richard Christopher Antonelli, MD, MS, Boston Children’s Hospital, Harvard Medical School, MA
  • Meika Neblett, MD, MS, Robert Wood Johnson Barnabas Health, NJ
  • Lisa C. Patton, PhD, JBS International, Inc., Bethesda, MD
  • David M. Shahian, MD, Harvard Medical School
  • Charleen Tachibana, DNP, RN, FAAN, Virginia Mason Franciscan Health, Seattle, WA
  • Andrew M. Wiesenthal, MD, SM, Deloitte Consulting, LLP, San Francisco, CA
  • Laurie Zephyrin, MD, MBA, MPH, The Commonwealth Fund, New York, NY

“Overall, the best part of working on the panel is seeing firsthand that the aspirations of John Eisenberg continue to inspire individuals and health systems across the country—and the bar keeps moving higher,” Dr. Clancy said. “Every year brings more ambitious and exciting submissions. Learning how systems across the country are pushing the limits of what can be considered excellence in healthcare is especially exciting for me.”

Learn more about this year’s recipients of the Eisenberg Awards



The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.